Clinical Systems for Patient Screening, Fire Prevention, Chamber Operations, Monitoring, and Emergency Response
Hyperbaric oxygen therapy places patients, personnel, medical equipment, and combustible materials in an environment where pressure and oxygen behave differently than they do under ordinary clinical conditions. These differences make hyperbaric medicine highly protocol driven.
Safe treatment requires more than operating a chamber correctly. It depends on coordinated clinical screening, fire prevention, equipment control, staff competency, continuous observation, preventive maintenance, and rehearsed emergency procedures.
In the United States, hyperbaric chambers are regulated as Class II medical devices. Facilities must operate each system according to its cleared intended use and the manufacturer’s instructions. Hyperbaric programs may also be subject to NFPA 99, healthcare accreditation requirements, building and fire codes, state regulations, and institutional policies. NFPA 99’s hyperbaric chapter addresses electrical, fire, pressure, and medical gas hazards associated with hyperbaric facilities. (NFPA LiNK)
Patient Screening Before Hyperbaric Oxygen Therapy
A comprehensive medical assessment should be completed before treatment begins. Screening identifies conditions that may increase the risks of pressure exposure, oxygen toxicity, barotrauma, glucose instability, or clinical deterioration inside the chamber.
The evaluation should consider:
- The clinical indication for HBOT
- Relevant pulmonary and cardiovascular history
- Previous pneumothorax or thoracic surgery
- Difficulty equalizing middle-ear or sinus pressure
- Seizure history and factors that may lower seizure threshold
- Diabetes and glucose-lowering medications
- Current respiratory infection, fever, or congestion
- Pregnancy status when clinically relevant
- Claustrophobia, anxiety, or cognitive impairment
- Implanted medical devices
- Medication interactions
- The patient’s ability to communicate during treatment
- The need for monitoring, ventilation, or other advanced support
An untreated pneumothorax presents a serious hazard because trapped pleural gas can expand during decompression. A history of spontaneous pneumothorax, significant pulmonary air trapping, bullous disease, or recent thoracic procedures also requires careful risk assessment. In emergency diving and hyperbaric situations, pneumothorax management may require specialized drainage and decompression strategies directed by experienced physicians. (UHMS)
Medication review is particularly important. Certain stimulants, psychiatric medications, antineoplastic agents, analgesics, antibiotics, withdrawal states, fever, and carbon dioxide retention may influence seizure risk or alter the patient’s response to hyperoxia. The hyperbaric physician should determine whether the medication can be continued, temporarily held, or accommodated through a modified treatment protocol. (UHMS)
Screening is not a one-time event. The clinical team should reassess the patient before every treatment because respiratory symptoms, medication use, glucose levels, wounds, dressings, and overall medical status can change during a treatment course.
Preventing Middle-Ear and Sinus Barotrauma
Pressure-related ear injury is among the most common complications of HBOT. During compression, the patient must actively equalize pressure between the middle ear and the chamber environment.
Before the first treatment, patients should be taught techniques such as swallowing, yawning, jaw movement, the Toynbee maneuver, or a gentle Valsalva maneuver when medically appropriate. Demonstration and coaching are more effective than simply instructing the patient to “clear the ears.”
Compression should be slowed or stopped when a patient reports pain, pressure, or an inability to equalize. Continuing compression against significant discomfort can produce tympanic membrane injury, middle-ear bleeding, or more severe barotrauma.
Patients with severe congestion, upper respiratory illness, sinus obstruction, previous ear surgery, or persistent equalization difficulty may require additional assessment. In selected cases, an otolaryngology evaluation or tympanostomy tube placement may be appropriate before continuing treatment. Patient preparation, staff vigilance, and early response to discomfort can substantially influence the frequency and severity of ear injuries. (UHMS)
Compassionate communication is also a safety intervention. Patients should know that reporting ear pain will not be viewed as noncompliance. Prompt reporting allows the operator to adjust compression before discomfort becomes an injury.
Fire Prevention in Hyperbaric Chambers
Fire is one of the most serious hazards in hyperbaric medicine. Oxygen does not ignite by itself, but increased oxygen concentration can lower ignition thresholds and cause combustible materials to burn more rapidly and intensely.
In August 2025, the FDA reminded healthcare providers to follow chamber manufacturers’ instructions, maintain staff training, use appropriate grounding, avoid prohibited or static-generating items, control clothing and linens, perform equipment maintenance, and maintain fire-prevention procedures. The communication followed reports of serious hyperbaric chamber fires that resulted in injuries and deaths. (U.S. Food and Drug Administration)
Every potential fuel and ignition source should be controlled. Items commonly restricted or prohibited unless specifically evaluated include:
- Cell phones, tablets, headphones, and personal electronics
- Battery-powered devices
- Lighters, matches, and heating elements
- Synthetic, wool, or silk clothing
- Petroleum-based products
- Alcohol-containing products that have not fully evaporated
- Aerosols
- Cosmetics, hair products, and certain skin preparations
- Unapproved blankets, pillows, or linens
- Hand warmers and chemical heat packs
- Medical equipment not evaluated for hyperbaric use
A product that is acceptable elsewhere in a hospital is not automatically safe inside a hyperbaric chamber. The hyperbaric safety program should require a documented risk assessment for every dressing, device, medication container, monitoring accessory, and patient-care item introduced into the chamber environment. The assessment should consider flammability, static generation, electrical energy, heat production, vapor release, battery chemistry, chamber atmosphere, and total fuel load. (UHMS)
Patients should change into facility-approved attire and remove personal belongings before treatment. In oxygen-filled monoplace chambers, proper grounding of the patient and chamber helps reduce static electricity risk. Grounding systems must be checked and maintained according to the chamber manufacturer’s instructions and applicable safety standards. (UHMS)
The Pre-Treatment Hyperbaric Safety Check
A standardized safety pause should occur before every chamber cycle. It provides a final opportunity to identify errors before the patient is exposed to increased pressure and oxygen.
The Undersea and Hyperbaric Medical Society recommends a documented process confirming the right patient, right treatment, and right safety conditions. (UHMS)
A pre-treatment check commonly verifies:
- Two patient identifiers
- The prescribed diagnosis and treatment profile
- Current vital signs and clinical stability
- Blood glucose when indicated
- Ear-equalization ability
- Removal of prohibited items
- Approved clothing, linens, and dressings
- Patient grounding for applicable monoplace systems
- Oxygen-delivery system fit and function
- Chamber communication
- Monitoring equipment operation
- Appropriate positioning of lines and tubes
- Emergency equipment availability
- Staff assignments and supervision
- Documentation of any protocol modification
The checklist should be specific enough to prevent omissions but brief enough to be performed consistently. Simply checking boxes without visually confirming the patient, chamber, and equipment can create a false sense of security.
Interruptions and unrelated activity should be limited during patient preparation and chamber operation. Hyperbaric safety guidance identifies distraction and complacency as factors that can contribute to mistakes. (UHMS)
Blood Glucose Management During HBOT
Patients with diabetes require a defined glucose-management protocol. Changes in meal timing, insulin administration, glucose-lowering medication, infection, physical stress, and the treatment schedule may contribute to glucose instability.
Facilities commonly check glucose before treatment and repeat testing afterward according to institutional policy and the patient’s clinical risk. The patient should also be assessed for recent hypoglycemia, reduced oral intake, changes in medication, and symptoms that could become difficult to interpret at pressure.
A low or rapidly falling glucose level should be corrected before treatment. Staff should know how glucose will be treated if symptoms develop inside the chamber and which carbohydrate products are approved for the specific chamber environment.
Numeric treatment thresholds should be established by the facility’s medical director rather than applied universally. Safe decisions depend on the patient’s baseline glucose, medication profile, recent trends, chamber type, treatment length, and access to the patient during the session. UHMS-associated nursing guidance emphasizes pre-treatment assessment, coordination with medication timing, and prevention of in-chamber hypoglycemia. (UHMS)
Monitoring Patients Under Pressure
Patients must remain under continuous observation throughout compression, oxygen exposure, air breaks, and decompression.
Monitoring should be appropriate to the patient’s acuity and may include:
- Visual observation
- Two-way voice communication
- Heart rate and blood pressure
- Cardiac rhythm
- Respiratory status
- Oxygen-delivery system performance
- Neurologic status
- Blood glucose
- Ventilator parameters
- Infusion status
- Pain, anxiety, or ear symptoms
Pulse oximetry has limited value for confirming the hyperbaric oxygen dose because hemoglobin is usually already highly saturated. It may still be useful for detecting equipment problems or changes during air breathing, depending on the clinical context.
The chamber operator should watch for early signs of oxygen intolerance, including facial twitching, visual changes, nausea, dizziness, unusual behavior, anxiety, or neurologic symptoms. Oxygen-induced seizures are uncommon but remain a recognized risk. If a seizure occurs, the immediate priorities are to protect the patient from injury, discontinue oxygen exposure when operationally possible, maintain the airway, and follow the facility’s emergency protocol. Decompression should be controlled because an uncontrolled pressure change can create additional risk.
The attending physician is responsible for selecting the treatment profile, managing complications, documenting the procedure, and ensuring that specialized nursing or respiratory support is available when required. (UHMS)
Medical Equipment and Implanted Devices
Medical devices must be evaluated before exposure to increased pressure or an oxygen-enriched environment. Pressure can affect gas-filled components, seals, displays, batteries, alarms, flow delivery, sensor accuracy, and mechanical performance.
The clinical team should confirm:
- The device manufacturer’s pressure rating
- Compatibility with the planned chamber atmosphere
- Whether the device contains a battery or ignition source
- Whether external components can remain outside the chamber
- How tubing and cables will pass through approved penetrators
- Whether pressure changes alter flow or dose delivery
- Whether emergency removal or disconnection is possible
- Whether testing or manufacturer consultation is required
Implanted devices require similar review. Pacemakers, defibrillators, infusion systems, pumps, neurostimulators, and other implants should not be cleared based only on the general device category. The exact manufacturer, model, programmed mode, and pressure limit should be verified.
The final decision should be documented by the hyperbaric physician and safety director using device labeling, manufacturer information, clinical necessity, and a formal risk assessment.
Chamber Operation and Preventive Maintenance
Hyperbaric chambers should be operated only by personnel trained for the specific system. Training must include normal operation, pressure control, oxygen delivery, patient communication, emergency decompression, fire response, equipment failure, and post-event reporting.
Preventive maintenance should follow the manufacturer’s schedule and applicable regulatory or accreditation requirements. Maintenance commonly includes inspection and testing of:
- Chamber doors and seals
- Pressure-control systems
- Relief valves
- Oxygen and air supplies
- Grounding systems
- Communications
- Fire-suppression equipment
- Oxygen-monitoring systems
- Electrical components
- Viewports
- Piping, valves, and penetrators
- Emergency controls
Maintenance records should identify the work performed, date, responsible technician, findings, corrective actions, and return-to-service authorization.
A chamber should not remain in operation simply because a defect appears minor. Changes in pressure performance, unusual sounds, oxygen leakage, failed communications, damaged seals, alarms, or inconsistent control behavior require evaluation before further patient use. The FDA specifically advises facilities to perform regular maintenance and follow each device’s instructions for use. (U.S. Food and Drug Administration)
Emergency Preparedness and Staff Drills
Hyperbaric emergencies are uncommon, which can make regular drills even more important. Staff must be able to respond without relying on improvisation during a high-pressure event.
Emergency procedures should address:
- Fire inside or near the chamber
- Loss of oxygen or compressed-air supply
- Power failure
- Communication failure
- Patient seizure
- Cardiac or respiratory arrest
- Acute chest pain or respiratory distress
- Suspected pneumothorax
- Severe hypoglycemia
- Oxygen-delivery system failure
- Unplanned decompression
- Entrapment or door malfunction
- Facility evacuation
Each protocol should define who stops oxygen flow, who initiates decompression, who contacts emergency services, who retrieves emergency equipment, and who maintains observation of other patients.
Multiplace programs also require clear inside-attendant staffing and decompression policies. Staff exposed to pressure must be medically fit, appropriately trained, and managed to limit occupational pressure and oxygen exposure. UHMS emphasizes that safe multiplace operations depend on appropriate patient-to-staff ratios and trained personnel both inside and outside the chamber. (UHMS)
Drills should be documented and evaluated. The purpose is not merely to prove that a drill occurred. It is to identify communication gaps, delayed actions, unclear responsibilities, inaccessible equipment, and steps that do not function as intended.
Documentation, Event Review, and Safety Culture
Every treatment record should document the prescribed protocol, pressure, oxygen periods, air breaks, treatment duration, patient response, monitoring, complications, and any deviation from the original plan.
Near misses should be reviewed with the same seriousness as events that cause harm. A prohibited item discovered before compression, a communication failure detected during setup, or an incorrect treatment profile caught during the safety pause provides valuable information about weaknesses in the system.
A strong hyperbaric safety culture gives all team members the authority to stop a treatment when a concern has not been resolved. This includes chamber operators, nurses, technicians, respiratory therapists, safety personnel, and physicians.
Patients also play an important role. They should be encouraged to report new medications, congestion, ear discomfort, low glucose symptoms, anxiety, and any personal item that may have been brought into the treatment area. Clear explanations help patients understand that chamber restrictions are not arbitrary. They are safeguards designed for an environment in which a seemingly ordinary object can create an unusual hazard.
Safe hyperbaric medicine depends on consistent execution. Patient screening, equipment review, fire prevention, staff training, treatment monitoring, and emergency preparedness must function as one integrated system. When safety becomes part of every clinical decision rather than a separate administrative exercise, the chamber environment can be managed with the discipline required for reliable, compassionate care.
